Thrombotic CVA and ST-Elevation Myocardial Infarction, Concomitant or Coincidence?

A Case Report

Background: Vascular disease is one of the major cause of morbidity and mortality
nowadays. With high incidence and wide diversity of presentation, profound
understanding and experience are elementary for every physician. Among many
vascular diseases, cerebrovascular accident and acute coronary syndrome remain to
be the major player. Ranking the top 2 mortality rate in recent Global Health
Estimate doesnt stop their vices. In rare case, both disease may present at the
same time, complicating both management and outcome.

Case Report: 50 year old Javanese male presented to the ER with sudden decrease of
consciousness 2 hours before presentation, preceded by vomitting. No history of
chest pain nor headache was obtained. Physical examination revealed patient with
Glasgow Coma Scale of 10, 200/100 mmHg blood pressure, 130 regular bpm heart rate,
20 respiratory rate, and 98% blood oxygen saturation. Rhonki observed on bilateral
chest on thorax physical examination. Right lateralization was found during
neurological examination. Other examination showed no remarkable finding. ECG
revealed ST elevation on lead I, aVL, V1 to V6. Complete blood count showed
elevated WBC with left shift CCreatinine was slightly elevated at 1.77 mg/dL. Blood
Gas Analysis revealed respiratory alkalosis compensated with metabolic acidosis.
Kalium level was slightly decreased at 3.30 mmol/L. Chest X-Ray revealed
cardiomegaly with pulmonary edema. Head CT scan without contrast revealed wide
infarction at right brain hemisphere.

Discussion: Thrombotic CVA and ST-Elevation Myocardial Infarction shared

pathophysiology to some extent. Both disease can cause the other, or, in rare case,
occured concomitantly. CVA can result in myocardial necrosis through activation of
sympathetic system. Large Myocardial Infarction may lead to worsening of
hemodynamically significant carotid disease. On the other hand, CVA and Myocardial
Infarction can occur at the same time secondary to some disease such as during
embolic phenomenon. A physician should remain aware of those possibilities during
diagnosis establishment. In this particular case, due to limitations in our
resources, there has been some difficulties in recognizing the definite cause.
However, patient underwent gradual improvement during therapy and showed no
morbidity afterwards.

Conclusion: Thrombotic CVA and Myocardial Infarction are vascular diseases that are
able to present at the same time, either concomitant or bilaterally causative. A
careful suspicion and meticulous diagnosis establishment must be held for every
physician.

Keywords: Vascular disease, Thrombotic CVA, Myocardial Infarction